Student Information System (SIS) Request for Account Access
Note: Access to the Mainframe must be granted before you can be granted access to SIS.
PLEASE TYPE OR PRINT CLEARLY
Last Name First Name M.I.
Job Title Academic Division/Administrative Unit Work Phone
I understand that I am responsible for all activities performed under my logon ID and password. I also understand that should I permit anyone else to use my authorization, I will be subject to losing access to the Student Information System for a period of time. If such a violation of security is repeated, I may lose access to the system entirely.
Signatures:
_____________________________________________________ _____________________________
Applicant Date
_____________________________________________________ _____________________________
Dean/ Director/ Department Head Date
_____________________________________________________ _____________________________
Executive Dean/Dean/ Vice Chancellor (as appropriate) Date
* * * * * * * * * * * * * * * * * * * * To Be Completed By Data Manager * * * * * * * * * * * * * * * * * * * * * *
ORGANIZATION SECURITY CLASS A B U (Circle One)
AUTHORIZED ACADEMIC UNIT C N (If Applicable)
AUTHORIZED DIVISION: _______ _______ ________ ________ ________
(If Applicable)
AUTHORIZED DEPARTMENTS: _______ _______ ________ ________ ________
(If Applicable)
AUTHORIZED MAJORS: _______ _______ ________ ________ ________
(If Applicable)
Type of Operator: ______________________________________ (Required)
Signature of Data Manager: ___________________________________________ Date: __________________________
* * * * * * * * * * * * * * * * To Be Completed By Office of Information Technology * * * * * * * * * * * * * * * * *
Completed by: ___________________________________________ Date: __________________________
Form 1822/003 (6/12)
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